The citation was F0684, the federal tag for failure to provide care that meets professional standards.
Nursing Home News — Page 610
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The resident, identified in inspection records only as R1, had just fallen face-first off the side of her bed and struck the bedside table.
That was the morning of September 4, 2025, at Geneva Lake Manor on South Curtis Street.
They told her she was being uncooperative.
She was documented as cognitively impaired and a fall risk.
The resident, identified in inspection records as R10, fell twice on September 26, 2025.
The problem was not isolated to one resident.
The resident had been discharged from a hospital with an order for ferrous sulfate 142 mg every Friday, to be given with vitamin C.
The Nursing Home Resident Care Staffing Report visible to anyone entering the facility that morning showed a date of November 2, day shift.
The declaration at The Lutheran Home: Belle Plaine was issued on October 22, 2025, and remained in place for nearly two weeks.
She did not notice he was carrying coffee.
Inspectors arrived on Halloween and found the gap that night.